ABSTRACT

According to WHO , Infertility is a disease of the male or female reproductive system defined
by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual
intercourse. Infertility affects millions of people of reproductive age worldwide – and has an
impact on their families and communities. Estimates suggest that between 48 million couples
and 186 million individuals live with infertility globally. In the male reproductive system,
infertility is most commonly caused by problems in the ejection of semen , absence or low
levels of sperm, or abnormal shape (morphology) and movement (motility) of the sperm. In
the female reproductive system, infertility may be caused by a range of abnormalities of the
ovaries, uterus, fallopian tubes, and the endocrine system, among others. Infertility can be
primary or secondary. Primary infertility is when a pregnancy has never been achieved by a
person, and secondary infertility is when at least one prior pregnancy has been achieved.
Fertility care encompasses the prevention, diagnosis and treatment of infertility. Equal and
equitable access to fertility care remains a challenge in most countries; particularly in low and
middle-income countries. Fertility care is rarely prioritized in national universal health
coverage benefit packages.
In general ,Infertility is the inability of a person, animal or plant to reproduce by natural
means. It is usually not the natural state of a healthy adult organism, except notably among
certain eusocial species (mostly haplo diploid insects).

In humans, infertility may describe a woman who is unable to conceive as well as being
unable to carry a pregnancy to full term. There are many biological and other causes of
infertility, including some that medical intervention can treat. Infertility rates have increased
by 4% since the 1980s, mostly from problems with fecundity due to an increase in age. About
40% of the issues involved with infertility are due to the man, another 40% due to the
woman, and 20% result from complications with both partners.
Women who are fertile experience a natural period of fertility before and during ovulation,
and they are naturally infertile during the rest of the menstrual cycle. Fertility awareness
methods are used to discern when these changes occur by tracking changes in cervical mucus
or basal body temperature Infertility is “a disease of the reproductive system defined by the
failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual
intercourse (and there is no other reason, such as breastfeeding or postpartum amenorrhea).
Primary infertility is infertility in a couple who have never had a child. Secondary infertility
is failure to conceive following a previous pregnancy. Infertility may be caused by infection
in the man or woman, but often there is no obvious underlying cause.

INTRODUCTION
Infertility was prevailing among society over long period of time but was rare . In recent
years due to lifestyle modifications of people there is an increasing rate of infertility. People
of this generation have infertility as an common one.Researchers commonly base
demographic studies on infertility prevalence on a five-year period. Practical measurement
problems, however, exist for any definition, because it is difficult to measure continuous
exposure to the risk of pregnancy over a period of years.

According to WHO, One in every four couples in developing countries had been found to
be affected by infertility, when an evaluation of responses from women in Demographic and
Health Surveys from 1990 was completed in collaboration with WHO in 2004.
The burden remains high. A WHO study, published at the end of 2012, has shown that the
overall burden of infertility in women from 190 countries has remained similar in estimated
levels and trends from 1990 to 2010.

The global health community has had great success in improving maternal and child health in
the past decade, partly through a focus on reproductive health . Infertility is a critical
component of reproductive health, and has often been neglected in these efforts . The
inability to have children affects men and women across the globe. Infertility can lead to
distress and depression, as well as discrimination and ostracism . An accurate profile of the
prevalence, distribution, and trends of infertility is an important first step towards shaping
evidence-based interventions and policies to reduce the burden of this neglected disability
globally.
Few comparative analyses of global infertility have been conducted, and none, to our
knowledge, have applied a consistent algorithm to demographic and reproductive health
survey data from both developing and developed countries, nor used these data to estimate
regional and global trends in infertility prevalence. Boivin et al. estimated global infertility by
summarizing prevalence data from seven studies: five from developed countries and two
from developing countries . A Demographic and Health Surveys (DHS) report also estimated
infertility for developing countries using survey data from 47 national DHS surveys . The
report's estimate of infertility and analysis of trends did not apply to developed countries, nor
to China. Ericksen and Brunette  and Larsen  applied consistent definitions of infertility in
their analyses of household survey data, but considered only Sub-Saharan African countries.
The main challenges in generating global estimates of infertility are the scarcity of
population-based studies and the inconsistent definitions used in the few high-quality studies
available . In population-based studies of infertility, there has been little consistency in how
prevalence is calculated . An explicit detailing of the numerator and denominator of each
definition is needed to make clear what is being measured. The authors of a recent literature
review concluded that it is not possible to synthesize infertility prevalence data in the
published literature because of the incomparable definitions used .
An alternative to synthesizing data found in the literature is to apply a consistent definition to
regularly collected demographic and reproductive health survey data. In this paper, we used a
consistent algorithm to measure infertility using household survey data. Our measure is a
demographic definition that uses live birth as the outcome and a 5-y exposure period based
on union status, use of contraceptives, and desire for a child . There are challenges associated
with inferring prevalence from household survey data. Few household surveys ask how long
the respondent has tried to get pregnant, and none include a comprehensive medical history
and clinical examination. Instead, these surveys may collect information on births, couple
status, fertility preferences, and contraceptive use. In a previous analysis we performed
sensitivity analyses around each of these components to identify important biases that may
arise when information is incomplete . We found that a 5-y exposure period is needed to
accommodate the time it takes to become pregnant and give birth, and helps prevent
unreported temporary separations, periods of postpartum sexual abstinence, or lactational
amenorrhea from unduly affecting the infertility measure. Births, rather than pregnancies, are
the preferred outcome, as information on live births is collected more often and reported
more accurately: neither pregnancies in the first trimester nor voluntary terminations are
reliably reported in household surveys . Lastly, we argued previously that the intent to have a
child serves as a proxy for regular, unprotected sexual intercourse, and may correct for
underreporting of contraceptive use .
Clinical and epidemiologic infertility definitions are also used to monitor infertility; however,
they are not appropriate when making population-based estimates of infertility using
household surveys. The clinical definition of infertility used by the World Health
Organization (WHO) is “a disease of the reproductive system defined by the failure to
achieve a clinical pregnancy after 12 months or more of regular unprotected sexual
intercourse”, while the WHO's epidemiologic definition is “women of reproductive age at
risk of becoming pregnant who report unsuccessfully trying for a pregnancy for more than
two years” . Clinical definitions are designed for early detection and treatment of infertility .
A definition and assessment of infertility based on medical histories and diagnostic tests is
appropriate for clinical settings, where the aim is to understand causes and provide treatment
as soon as it is indicated. However, measuring patterns and trends in infertility at the
population level necessitates a measure that may be elicited using a standard set of survey
questions . The WHO's epidemiologic definition is more closely aligned with clinical practice
than demographic definitions are, and may be measured using survey data. However, few
household surveys determine whether a couple is trying to become pregnant, and the majority
do not collect information on past pregnancies, only on previous live births.
In this study, we analyzed data from a range of reproductive and demographic surveys to
estimate infertility prevalence. We applied consistent definitions of primary infertility
(inability to have any live birth) and secondary infertility (inability to have an additional live
birth). We developed a Bayesian hierarchical model to generate estimates for levels and
trends of infertility and their uncertainties by country for the time period 1990 to 2010.
AIM AND OBJECTIVE
WHY I CHOSE INFERTILITY OVER OTHER TOPICS ?
I have chosen the topic – Infertility because it is one of the occurring problems faced by most
of the families. This causes a lot of problems emotionally as well as socially . the problem
might be either with male or female partner but anyway females are blamed for infertility. at
current affairs infertility cases are on a rise and also infertility clinics have increased. And
there is also a misconception that infertility problems only deals with women so as to make it
clear that most of the infertility problems deals with men. It’s a data that most of these
problems are 95% dealt with men and only rest of the 5% deals with women. So as to create a
clear mindset for the upcoming future society about these problems, I’ve chosen this topic.
The other main reason is that the IVF industry in India is on a growth path. However, the
industry is largely unregulated which can prove to be pernicious in the long run. Right from
changing our old mindsets to motivating technology has made things possible which weren’t
so before.

The wonder of IVF is one such example which has come as a boon to millions of couples
who face the scourge of infertility like a thorn in the flesh. Investors searching for a new way
to make big money in medicine have hit upon an age-old problem: infertility. So let’s look
over through it in depth.

METHODOLOGY
We accessed and analyzed household survey data from 277 demographic and reproductive
health surveys using a consistent algorithm to calculate infertility. We used a demographic
infertility measure with live birth as the outcome and a 5-y exposure period based on union
status, contraceptive use, and desire for a child. We corrected for biases arising from the use
of incomplete information on past union status and contraceptive use. We used a Bayesian
hierarchical model to estimate prevalence of and trends in infertility in 190 countries and
territories. In 2010, among women 20–44 y of age who were exposed to the risk of
pregnancy, 1.9% (95% uncertainty interval 1.7%, 2.2%) were unable to attain a live birth
(primary infertility). Out of women who had had at least one live birth and were exposed to
the risk of pregnancy, 10.5% (9.5%, 11.7%) were unable to have another child (secondary
infertility). Infertility prevalence was highest in South Asia, Sub-Saharan Africa, North
Africa/Middle East, and Central/Eastern Europe and Central Asia. Levels of infertility in
2010 were similar to those in 1990 in most world regions, apart from declines in primary and
secondary infertility in Sub-Saharan Africa and primary infertility in South Asia (posterior
probability [pp] ≥0.99). Although there were no statistically significant changes in the
prevalence of infertility in most regions amongst women who were exposed to the risk of
pregnancy, reduced child-seeking behavior resulted in a reduction of primary infertility
among all women from 1.6% to 1.5% (pp = 0.90) and a reduction of secondary infertility
among all women from 3.9% to 3.0% (pp>0.99) from 1990 to 2010. Due to population
growth, however, the absolute number of couples affected by infertility increased from 42.0
million (39.6 million, 44.8 million) in 1990 to 48.5 million (45.0 million, 52.6 million) in
2010. Limitations of the study include gaps in survey data for some countries and the use of
proxies to determine exposure to pregnancy.

STUDY DESIGN
We estimated prevalence of primary and secondary infertility, their trends between 1990 and
2010, and their uncertainties, in 190 countries and territories. We used survey data consisting
of interviews with the female partner. Although infertility occurs in couples and may have a
male or a female cause, estimates are indexed on the woman in each couple. We made
estimates for women aged 20–44 y, excluding infertility during the beginning (15–19 y) and
end (45–49 y) of the reproductive period, when fewer couples are seeking a child and
estimates of prevalence are less stable. We additionally estimated the proportion of women in
each region who were exposed to the risk of pregnancy, i.e., those who were in a union, were
not using contraceptives, and had a child or wished to have one, either her first (primary
infertility) or an additional (secondary infertility) child. We grouped the countries into the
seven regions (High Income, Central/Eastern Europe and Central Asia, East Asia/Pacific,
Latin America/Caribbean, North Africa/Middle East, Sub-Saharan Africa, and South Asia)
and 21 nested subregions of the Institute for Health Metrics and Evaluation Global Burden of
Disease 2010 study .
Our analysis included four steps: (1) identification and extraction of data, (2) adjustment of
extracted data for known biases as needed, (3) application of a statistical model to estimate
infertility prevalence and exposure proportion trends by country and age of the female
partner, and (4) calculation of the number of couples currently affected by infertility. We
calculated the estimates' uncertainty, taking into account both sampling error and uncertainty
from each step of statistical modeling.

DATA SOURCES
We included data from demographic and reproductive health surveys that we could obtain at
the (anonymized) individual level, and hence to which we could apply a consistent definition
of infertility. We identified data sources from national demographic studies in a recent
systematic literature review of infertility prevalence, as well as data that were known to the
authors of the present study. To be included, each survey had to collect women's age, current
couple status, current contraceptive use, time since first and last births, time since first union,
and desire to have a child. Data available only as summary statistics were excluded.
We obtained data from the following survey programs: DHS, Reproductive Health Surveys,
the World Fertility Survey, the Pan Arab Project for Family Health and Pan Arab Project for
Child Development, the European Multicenter Study on Infertility and Subfecundity, the
Fertility and Family Survey, the United States National Survey of Family Growth, and the
China In-Depth Fertility Sample Surveys; We included surveys prior to 1990 to capture
heterogeneity in levels of infertility in countries that did not have more recent surveys. For
each data source, we recorded information on survey population and sampling strategy. For
each female survey respondent, we extracted data on union (marriage or cohabitation), birth
history, contraceptive use status and history (if available), and the woman's desire for a child
or an additional child. We used stated desire for a child to exclude women who take
unreported actions to prevent pregnancies or births, including unreported periods of
abstinence or contraceptive use, or voluntary terminations. We included women who were
undecided about having additional children and women who declared they were unable to
become pregnant in the same category as women who stated they wanted another child,
because this group is less likely to be preventing pregnancies or births in ways that are not
captured by other survey questions. We refer to these women as women who desire a child.
We excluded ten Fertility and Family
Surveys and three Reproductive Health
Surveys because at least one response
was missing for more than 15% of
respondents.

ANALYSIS OF DATA
Mascarenhas et al. evaluated potential
bias from using standard demographic or
reproductive health surveys to estimate
infertility prevalence and recommended
the following standard algorithms ,
which we employed .
 Primary infertility is defined as the absence of a live birth for women who desire a
child and have been in a union for at least five years, during which they have not used
any contraceptives. The prevalence of primary infertility is calculated as the number
of women in an infertile union divided by the number of women in both infertile and
fertile unions, where women in a fertile union have successfully had at least one live
birth and have been in the union for at least five years at the time of the survey.
 Secondary infertility is defined as the absence of a live birth for women who desire a
child and have been in a union for at least five years since their last live birth, during
which they did not use any contraceptives. The prevalence of secondary infertility is
calculated as the number of women in an infertile union divided by the combined
number of women in infertile and fertile unions. Women in a fertile union have
successfully had at least one live birth in the past five years and, at the time of the
survey, have been in a union for at least five years following their first birth.
 
We also calculated the proportion of women of reproductive age (20–44 y) who are exposed
to the risk of pregnancy in order to calculate the overall percent of women who are affected
by unwanted infertility. Women are exposed if they are fertile, infertile, or their fertility
status is not determined at the time of the survey. Specifically:
 Exposure to primary infertility is defined as the number of women who are currently
in a union, are not using any contraceptives, and desire a child, as well as the women
who are currently in a union and have given birth to at least one child. The proportion
exposed is calculated as the number of women exposed over the total number of
women surveyed.
 Exposure to secondary infertility is defined as the number of women who have had at
least one live birth, are currently in a union, are not using any contraceptives, and
desire another child, as well as the women who are currently in a union and have
given birth to an additional child in the last 5 y. The proportion exposed is calculated
as the number of women exposed over the total number of women surveyed . A small
proportion of DHS surveys in high-fertility countries interview only women who have
been in a union. We used exposure data from these surveys for women over age 30 y,
as virtually all women in these countries have been in a union by age 30 y.

We applied the above definitions to all of the survey data, generating four indicators for each
survey: prevalence of primary and secondary infertility and exposure to primary and
secondary infertility. We calculated the effective sample size for each indicator to reflect the
subset of survey responses used to calculate primary and secondary infertility and to account
for sampling uncertainty .We did not calculate secondary infertility using survey data from
China or make estimates of secondary infertility for China, because survey-based estimates of
secondary infertility are difficult to interpret in a setting where government regulations
strongly affect decisions around limiting family size.

STATISTICAL ANALYSIS
Despite the large number of surveys used in this analysis, data were not available for many
country-years of interest. In addition, some of the surveys that we used were not nationally
representative. As a result, we developed a statistical model to generate estimates for every
country and year, including those for which no data were identified. We estimated four
indicators: the prevalence of primary infertility, the prevalence of secondary infertility, and
the proportion of couples exposed to each type of infertility .We made these estimates for 190
countries, the years 1990–2010, and each age group. We used a Bayesian hierarchical model
to makes estimates for each country-year-age grouping, informed by the unit, if available, and
by data from other units..
We fit a hierarchical model in which our estimates for countries were nested within
subregional, regional, and global levels. Because the model is hierarchical, estimates for each
country are informed by data from the country itself, if available, and by data from other
countries, especially countries in the same region. A hierarchical model shares information to
a greater degree when data are sparse, uncertain, or inconsistent, and to a lesser degree in
data-rich countries and regions. We also modeled hierarchical linear time trends. Specifically,
region-specific time trends were nested in a global trend. We used a time-varying covariate to
inform our estimates, namely, maternal education (average years of schooling for women of
reproductive age). Subnational studies are less informative than national studies, thus we
included separate variance components for subnational and national data sources. These
variance components were estimated as part of the model fitting process, allowing national
data to have greater influence on estimates than subnational data.
Age of the female partner is a major determinant of fertility. We made estimates by 5-y age
group for the ages 20–44 y, using indicator variables for each age category. This allowed us
to generate a fully flexible age pattern. While the increase in infertility with female age is
biologically determined, the age at which women wish to have a child is also culturally
determined. Thus, we allowed for different age patterns of exposure to primary fertility in the
High Income region, versus in other regions.
We estimated the following sources of uncertainty ,sampling uncertainty in the data sources,
uncertainty associated with the conversion from prevalence estimates using incomplete
information on contraceptive use and couple status, uncertainty from study design factors for
national surveys, additional uncertainty for non-national data sources, and uncertainty from
the use of a model to estimate prevalence of primary and secondary infertility by country,
year, and age group where data were not available.
We fit the Bayesian model using Markov chain Monte Carlo methods to obtain 1,600
samples from the posterior distribution of the model parameters, reflecting the uncertainty
from each step of the analysis; these parameter values were in turn used to calculate the
posterior distribution of each indicator. We calculated trends by subtracting the estimate for
1990 from the estimate for 2010 for each draw. We calculated central estimates as the mean
of the draws, and uncertainty intervals as the 2.5th–97.5th percentiles of these draws. We also
reported the posterior probability (pp) that an estimated increase or decrease corresponds to a
truly increasing or decreasing trend. pp's are not p-values; they are probabilities: if the pp of
an increase is 0.5 then an increase and a decrease are both equally likely, while a high pp of
an increase indicates high certainty that an increase occurred. We considered a trend to be
statistically significant if its pp was greater than 0.975. Survey analyses were carried out
using Stata 10.1, and Markov chain Monte Carlo analysis was carried out in Python using the
PyMC package.
We evaluated the predictive validity of our models' central estimates and their uncertainty
intervals by performing cross-validation. We ran each model five times, each time
withholding data from a random sample of 20% of countries. We then compared the model
predictions to the known-but-withheld data. For each model, we calculated the root mean
square error, median relative error, and the percent of withheld data that fell within the
model's 95% uncertainty interval.
We report four results: prevalence of primary and secondary infertility among child-seeking
women, i.e., among women who are exposed to the risk of pregnancy, and the percent of
primary and secondary infertility among all women of reproductive age, calculated as the
product of the prevalence of infertility among child-seeking women and the proportion who
are exposed to the risk of pregnancy. We also calculated the number of couples affected by
infertility using population data from the United Nations Population Division's “World
Population Prospects: 2010 revision” . We also report two additional indicators, percent of
women exposed to the risk of primary and secondary infertility, in Figures H, I, M, and N.
All estimates were made by country and age; we calculated all-age, regional, and global
estimates by weighting country- and age-specific estimates by the population of women in
the relevant age group.

EFFECTS
Psychological impact

The consequences of infertility are manifold and can include societal repercussions and
personal suffering. Advances in assisted reproductive technologies, such as IVF, can offer
hope to many couples where treatment is available, although barriers exist in terms of
medical coverage and affordability. The medicalization of infertility has unwittingly led to a
disregard for the emotional responses that couples experience, which include distress, loss of
control, stigmatization, and a disruption in the developmental trajectory of adulthood.

Infertility may have profound psychological effects. Partners may become more anxious to
conceive, increasing sexual dysfunction Marital discord often develops in infertile couples,
especially when they are under pressure to make medical decisions. Women trying to
conceive often have clinical depression rates similar to women who have heart disease or
cancer. Even couples undertaking IVF face considerable stress.

The emotional losses created by infertility include the denial of motherhood as a rite of
passage; the loss of one’s anticipated and imagined life; feeling a loss of control over one’s
life; doubting one’s womanhood; changed and sometimes lost friendships; and, for many, the
loss of one’s religious environment as a support system.

Emotional stress and marital difficulties are greater in couples where the infertility lies with
the man.
Social impact

In many cultures, inability to conceive bears a stigma. In closed social groups, a degree of
rejection (or a sense of being rejected by the couple) may cause considerable anxiety and
disappointment. Some respond by actively avoiding the issue altogether; middle-class men
are the most likely to respond in this way.
In an effort to end the shame and secrecy of infertility, Redbook in October 2011 launched a
video campaign, The Truth About Trying, to start an open conversation about infertility,
which strikes one in eight women in the United States. In a survey of couples having
difficulty conceiving, conducted by the pharmaceutical company Merck, 61 percent of
respondents hid their infertility from family and friends. Nearly half didn't even tell their
mothers. The message of those speaking out: It's not always easy to get pregnant, and there's
no shame in that.

There are legal ramifications as well. Infertility has begun to gain more exposure to legal
domains. An estimated 4 million workers in the U.S. used the Family and Medical Leave Act
(FMLA) in 2004 to care for a child, parent or spouse, or because of their own personal
illness. Many treatments for infertility, including diagnostic tests, surgery and therapy for
depression, can qualify one for FMLA leave. It has been suggested that infertility be
classified as a form of disability.

CAUSES

Sexually transmitted disease

Infections with the following sexually transmitted pathogens have a negative effect on
fertility: Chlamydia trachomatis, Neisseria gonorrhoeae, and Syphilis. There is a consistent
association of Mycoplasma genitalium infection and female reproductive tract syndromes. M.
genitalium infection is associated with increased risk of infertility.
Genetic

A Robertsonian translocation in either partner may cause recurrent spontaneous abortions or

complete infertility.

Other causes

Factors that can cause male as well as female infertility are:

• DNA damage

• DNA damage reduces fertility in female ovocytes, as caused by smoking, other xenobiotic
DNA damaging agents (such as radiation or chemotherapy)or accumulation of the oxidative
DNA damage 8-hydroxy-deoxyguanosine

• DNA damage reduces fertility in male sperm, as caused by oxidative DNA damage,
smoking, other xenobiotic DNA damaging agents (such as drugs or chemotherapy)or other
DNA damaging agents including reactive oxygen species, fever or high testicular
temperature.
 DNA DAMAGE IN SPERM

General factors

• Diabetes mellitus, thyroid disorders, undiagnosed and untreated coeliac disease adrenal
disease

• Hypothalamic-pituitary factors

• Hyperprolactinemia

• Hypopituitarism

• The presence of anti-thyroid antibodies is associated with an increased risk of unexplained

subfertility with an odds ratio of 1.5 and 95% confidence interval of 1.1–2.0

• Environmental factors
• Toxins such as glues, volatile organic solvents or silicones, physical agents, chemical dusts,
and pesticides Tobacco smokers are 60% more likely to be infertile than non-smokers.

German scientists have reported that a virus called Adeno-associated virus might have a role
in male infertility, though it is otherwise not harmful. Other diseases such as chlamydia and
gonorrhea can also cause infertility, due to internal scarring (fallopian tube obstruction).

INFERTILTIY IN FEMALES

The following causes of infertility may only be found in females. For a woman to conceive,
certain things have to happen: intercourse must take place around the time when an egg is
released from her ovary; the system that produces eggs has to be working at optimum levels;
and her hormones must be balanced.

For women, problems with fertilization arise mainly from either structural problems in the
Fallopian tube or uterus or problems releasing eggs. Infertility may be caused by blockage of
the Fallopian tube due to malformations, infections such as Chlamydia and/or scar tissue. For
example, endometriosis can cause infertility with the growth of endometrial tissue in the
Fallopian tubes and/or around the ovaries. Endometriosis is usually more common in women
in their mid-twenties and older, especially when postponed childbirth has taken place.

Another major cause of infertility in women may be the inability to ovulate. Malformation of
the eggs themselves may complicate conception. For example, polycystic ovarian syndrome
is when the eggs only partially developed within the ovary and there is an excess of male
hormones. Some women are infertile because their ovaries do not mature and release eggs. In
this case synthetic FSH by injection or Clomid (Clomiphene citrate) via a pill can be given to
stimulate follicles to mature in the ovaries.
Other factors that can affect a woman's chances of conceiving include being overweight or
underweight, or her age as female fertility declines after the age of 30.

Sometimes it can be a combination of factors, and sometimes a clear cause is never

established.

Common causes of infertility of females include:

• Ovulation problems (e.g. polycystic ovarian syndrome, PCOS, the leading reason why
women present to fertility clinics due to anovulatory infertility)

• tubal blockage

• pelvic inflammatory disease caused by infections like tuberculosis

• age-related factors

• uterine problems

• previous tubal ligation

• endometriosis

• advanced maternal age

 INFERTILITY IN MALES

The main cause of male infertility is low semen quality. In men who have the necessary
reproductive organs to procreate, infertility can be caused by low sperm count due to
endocrine problems, drugs, radiation, or infection. There may be testicular malformations,
hormone imbalance, or blockage of the man's duct system. Although many of these can be
treated through surgery or hormonal substitutions, some may be indefinite. Infertility
associated with viable, but immotile sperm may be caused by primary ciliary dyskinesia.

Combined infertility

In some cases, both the man and woman may be infertile or sub-fertile, and the couple's
infertility arises from the combination of these conditions. In other cases, the cause is
suspected to be immunological or genetic; it may be that each partner is independently fertile
but the couple cannot conceive together without assistance.
Unexplained infertility

In the US, up to 20% of infertile couples have unexplained infertility.In these cases
abnormalities are likely to be present but not detected by current methods. Possible problems
could be that the egg is not released at the optimum time for fertilization, which it may not
enter the fallopian tube, sperm may not be able to reach the egg, fertilization may fail to
occur, transport of the zygote may be disturbed, or implantation fails. It is increasingly
recognized that egg quality is of critical importance and women of advanced maternal age
have eggs of reduced capacity for normal and successful fertilization. Also, polymorphisms
in folate pathway genes could be one reason for fertility complications in some women with
unexplained infertility.

TREATMENT

Treatment depends on the cause of infertility, but may include counseling, fertility
treatments, which include in vitro fertilization. According to ESHRE recommendations,
couples with an estimated live birth rate of 40% or higher per year are encouraged to continue
aiming for a spontaneous pregnancy. Treatment methods for infertility may be grouped as
medical or complementary and alternative treatments. Some methods may be used in concert
with other methods. Drugs used for both women and men includeclomiphene citrate, human
menopausal gonadotropin (hMG), follicle-stimulating hormone (FSH), human chorionic
gonadotropin (hCG), gonadotropin-releasing hormone (GnRH)analogues, aromatase
inhibitors, and metformin.
Medical treatments

Medical treatment of infertility generally involves the use of fertility medication, medical
device, surgery, or a combination of the following. If the sperm are of good quality and the
mechanics of the woman's reproductive structures are good (patent fallopian tubes, no
adhesions or scarring), a course of ovarian stimulating medication maybe used. The physician
or WHNP may also suggest using a conception cap cervical cap, which the patient uses at
home by placing the sperm inside the cap and putting the conception device on the cervix, or
intrauterine insemination (IUI), in which the doctor or WHNP introduces sperm into the
uterus during ovulation, via a catheter. In these methods, fertilization occurs inside the body.

If conservative medical treatments fail to achieve a full term pregnancy, the physician or
WHNP may suggest the patient undergo in vitro fertilization (IVF). IVF and related
techniques (ICSI, ZIFT, and GIFT) are called assisted reproductive technology (ART)
techniques.

ART techniques generally start with stimulating the ovaries to increase egg production. After
stimulation, the physician surgically extracts one or more eggs from the ovary, and unites
them with sperm in a laboratory setting, with the intent of producing one or more embryos.
Fertilization takes place outside the body, and the fertilized egg is reinserted into the woman's
reproductive tract, in a procedure called embryo transfer

Other medical techniques are e.g. tuboplasty, assisted hatching, and Preimplantation genetic
diagnosis.

EFFECTS ON THE POPULATION

Perhaps except for infertility in science fiction, films and other fiction depicting emotional
struggles of assisted reproductive technology have had an upswing first in the latter part of
the 2000s decade, although the techniques have been available for decades. Yet, the number
of people that can relate to it by personal experience in one way or another is ever growing,
and the variety of trials and struggles is huge.

Pixar's Up contains a depiction of infertility in an extended life montage that lasts the first
few minutes of the film.

There are several ethical issues associated with infertility and its treatment.

• High-cost treatments are out of financial reach for some couples.

• Debate over whether health insurance companies (e.g. in the US) should be required to
cover infertility treatment.

• Allocation of medical resources that could be used elsewhere

• The legal status of embryos fertilized in vitro and not transferred
in vivo. (See also Beginning of pregnancy controversy

• Pro-life opposition to the destruction of embryos not transferred in vivo.

• IVF and other fertility treatments have resulted in an increase in multiple births, provoking
ethical analysis because of the link between multiple pregnancies, premature birth, and a host
of health problems.

• Religious leaders' opinions on fertility treatments; for example, the Roman Catholic Church
views infertility as a calling to adopt or to use natural treatments (medication, surgery, and/or
cycle charting) and members must reject assisted reproductive technologies.

• Infertility caused by DNA defects on the Y chromosome is passed on from father to son. If
natural selection is the primary error correction mechanism that prevents random mutations
on the Y chromosome, then fertility treatments for men with abnormal sperm (in particular
ICSI) only defer the underlying problem to the next male generation.

Many countries have special frameworks for dealing with the ethical and social issues around
fertility treatment.

• One of the best known is the HFEA – The UK's regulator for fertility treatment and embryo
research. This was set up on 1 August 1991 following a detailed commission of enquiry led
by Mary Warnock in the 1980s

• A similar model to the HFEA has been adopted by the rest of the countries in the European
Union. Each country has its own body or bodies responsible for the inspection and licensing
of fertility treatment under the EU Tissues and Cells directive

• Regulatory bodies are also found in Canada and in the state of Victoria in Australia.

SUMMARY AND CONCLUSION

Infertility is often not seen (by the West) as being an issue outside industrialized
countries.This is because of assumptions about overpopulation problems and hyper fertility in
developing countries, and a perceived need for them to decrease their populations and birth
rates. The lack of health care and high rates of life-threatening illness (such as HIV/AIDS) in
developing countries, such as those in Africa, are supporting reasons for the inadequate
supply of fertility treatment options.Fertility treatments, even simple ones such as treatment
for STIs that cause infertility, are therefore not usually made available to individuals in these
countries.
Despite this, infertility has profound effects on individuals in developing countries, as the
production of children is often highly socially valued and is vital for social security and
health networks as well as for family income generation. Infertility in these societies often
leads to social stigmatization and abandonment by spouses.Infertility is, in fact, common in
sub-Saharan Africa. Unlike in the West, secondary infertility is more common than primary
infertility, being most often the result of untreated STIs or complications from
pregnancy/birth.

Due to the assumptions surrounding issues of hyper-fertility in developing countries, ethical

controversy surrounds the idea of whether or not access to assisted reproductive technologies
should comprise a critical aspect of reproductive health or at least, whether or not the
distribution and access of such technologies should be subject to greater equity. However, as
highlighted by Inhorn the overarching conceptualization of infertility, to a great extent,
disguises important distinctions that can be made within a local context, both
demographically and epidemiological and moreover, that these factors are highly significant
in the ethics of reproduction.

An important factor, argues Inhorn, is the positioning of men within the paradigm of
reproductive health, whereby because rates of general infertility mask differences between
male and female infertility, men remain a largely invisible facet within the theorisation and
discourse surrounding infertility, as well as the related treatments and biotechnologies. This is
particularly significant given that male infertility accounts for more than half of all cases of
infertility and moreover, it is evident that the attitudes and behaviours of men have profound
implications for the reproductive health of both individuals and couples. For example, Inhorn
notes that when couples in Egypt are faced with seemingly intractable infertility problems -
due to a range of family and societal pressures that centre around the place of children in
constituting the gender identity of men and women - it is often the women who is forced to
seek continued treatment; this continues to occur, even in known instances of male infertility
and that the constant seeking of treatment frequently becomes iatrogenic for the women.

Inhorn states that infertility often leads to “marital demise, physical violence, emotional
abuse, social exclusion, community exile, ineffective and iatrogenic therapies, poverty, old
age insecurity, increased risk of HIV/AIDS, and death”Significantly, Inhorn demonstrates
that this phenomenon cannot simply be explained by a lack of knowledge, rather it occurs in
a complex interaction between the centrality of children in the male gender identity as a
symbol of maturity and the relative lack of power of women in Egyptian society, whereby
they effectively become scapegoats for a culturally accepted narrative as a site of blame for
the lack of childlessness. It should be emphasised that this is not simply an issue of “women
oppressed by men” but rather, that men and women both share the burden of this narrative,
but in different, unequal and highly complex ways.

Therefore, while the notion that reproductive health is a ‘women’s issue’, may have powerful
social currency, especially within popular discourse and indigenous systems of meaning, the
reality of infertility suggests that medical and health paradigms have a significant part to play
in challenging the validity of this entrenched belief . Moreover, the effectiveness of any
therapeutic intervention, medical or otherwise will be contingent on such outcomes and has
an important part to play in the alleviation of gendered suffering, especially the burden
imposed on women, who continue to suffer disproportionately from the effects of infertility.

High costs may also be a factor and research by the Genk Institute for Fertility Technology,
in Belgium, claimed a much lower cost methodology (about 90% reduction) with similar
efficacy, which may be suitable for some fertility treatment. At the 1994 United Nations
International Conference on Population and Development (ICPD) in Cairo, the prevention
and treatment of infertility was accepted into the program of action for reproductive
healthcare. Infertility has shown to have a greater affect on developing nations than on birth
rates or population control, but also on a social level as well.

Reproduction is a large aspect of life for many cultures within developing nations, and
infertility can lead to social and familial problems such as rejection or abandonment as well
as personal psychological issues. Currently, fertility treatment options and programs are only
available through private health sectors in developing nations and little-to-no treatment is
available through public health sectors. The fertility treatment options offered through the
private sectors are often costly or not easily accessible. Additionally, counseling is considered
an essential aspect of fertility treatment, and due to lack of education and resources such
forms of therapy remain scarce as well. The lack of fertility treatment is problematic, and
high birth and population rates are every reason to implement treatment options rather than
reject them.
 REFERENCES

 NCERT TEXT BOOK

 wikipedia
 * www.who.int/reproductivehealth/publications/infertility
 www.who.int/reproductivehealth/topics/infertility/
 icmr.nic.in/ijmr/2011/
 www.who.int/bulletin/volumes/
 www.ncbi.nlm.nih.gov/pmc/articles/
 www.who.int/reproductivehealth/topics
 www.ncbi.nlm.nih.gov